Equity in Heart Failure Care

14 Sep 2011

Compared to all other Truman Medical Center (TMC) patients, those with heart failure (HF) were found to have twice the number of emergency department visits, five times the number of hospitalizations and five times the cost. To tackle this issue, TMC, part of the Kansas City Alliance and a member of the AF4Q Equity Quality Improvement Collaborative (EQIC), implemented a standardized approach to HF education at discharge, called “Living with Heart Failure.” A health coach uses this to reinforce self-management skills during post-discharge follow-up calls. For those who also have multiple co-existing chronic illnesses and social complexity, TMC has implemented the “Guided Chronic Care” program, a comprehensive approach for improving HF quality of life and mitigating social barriers so patients can take advantage of care offered to them. A nurse and social worker support these patients across the continuum, in the space between encounters, act as advocates for them as needed, but consistently promote self-management skills at whatever level the patient is ready. Patient and family needs are assessed and supported where appropriate and possible, shared goals are established and consultants engaged, such as initiation of a pharmacy consultation for patients with five or more medications.